Background Intramedullary spinal cord lesions prove to be a diagnostic challenge due to their non-specific clinical and radiological presentation. There is a preference for empiric medical therapy, given the inherent risks of surgical intervention to the spine. These factors can lead to delay in diagnosis. Primary central nervous system lymphoma is a rare cause and presents with atypical features in the immunosuppressed patient, including a lack of response to steroid therapy. Case Description We present a 64-year-old male patient with underlying sarcoidosis who reported progressive neuropathy with imaging showing a spinal cord lesion. Based on the above, multiple courses of empiric therapy were employed, including systemic steroids, chemotherapy and immunotherapy. Despite this, there was further clinical deterioration and interim imaging showed disease progression. The decision was made to perform open biopsy of the spinal cord lesion to aid diagnosis. Histological analysis diagnosed Epstein-Barr virus (EBV)-positive high grade large B-cell lymphoma. The patient received rituximab and methotrexate with radiological response but no clinical benefit. He continued to suffer treatment-related complications including encephalopathy and recurrent infections which eventually lead to death. Conclusions Primary central nervous system lymphoma is an aggressive disease and failure to respond to empiric treatment should prompt clinician’s to consider biopsy for definitive diagnosis. A lack of response to steroids does not exclude lymphoma.

Background The extent of neck dissection for tongue SCC is unclear owing to the potential presence of occult level IV metastasis. We aim to assess the incidence of occult level IV nodal metastasis for tongue SCC patients treated in our centre over a 20 year period. Methods A retrospective analysis of data collected from 1999 to 2019 was performed. Patients diagnosed with oral tongue SCC treated primarily with surgery and a neck dissection fulfilled the inclusion criteria. Results A total of 124 patients were included in our study. Sixty‐one patients were N0 with no occult level IV metastasis. About 17.3% of clinically node positive patients had level IV metastasis. Length of hospital stay and complication rates were comparable for patients who received levels I–III and I–IV neck dissections. Conclusion Occult level IV metastasis in N0 tongue SCC patients are exceedingly rare, we would therefore suggest consideration for a level I–III neck dissection. In patients who are clinically node positive, a level I–IV neck dissection would be recommended.

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